Who the Health Cares? Season 2 Episode 5 Transcript

Former Health Secretary Umair Shah on AI, MAHA, and Leadership Lessons

In our last episode, we talked about how public health leaders and communities respond to natural disasters, from tornados to pandemics, and the ways in which those emergency response efforts expose both the strengths and the limits of our public health system.

But most days don’t require emergency response protocols. Most days involve the normal hub of activity, handing out birth certificates, conducting restaurant inspections, implementing wellness programs.

But always in the background, even on the most quiet and average day, public health leaders need to be thinking about and planning how to respond to a complicated political environment and to changes in technology that offer both promise and peril.

For example, for local health officials, a constant question is how to respond to their counterparts at the state and federal level. These officials also need to think about how world changing technologies, such as the sudden ubiquity of artificial intelligence, can or should impact their work. And there is the ever present question of how their work connects with the broader medical and social services system.

From the Center for Public Health Systems at Columbia University, this is “Who the Health Cares,” a podcast about the history, politics, and substance of our public health system. I’m your host, Michael Sparer.

On today’s episode, we’re taking a closer look at how public health leaders are responding to a complicated and changing political and data environment.

I’m joined by Dr. Umair Shah, Chief Medical Officer for Phamily, an AI-powered health care platform. Umair started out as an ER physician before moving into the public health field. He served as the executive director of the Harris County health department in Texas for several years, and then as Secretary of Health for the state of Washington where he helped lead the state’s COVID vaccine rollout.

Given Umair’s experience across both clinical care and public health – and at both the local and state levels – I was eager to hear his perspective on how the field is evolving in a time of technological and political disruption.

Michael: Hi, Umair, thank you so much for joining us today.

Umair: Excited to be here. Thanks for having me.

Michael: Uh, I'm really looking forward to chatting with you. Uh, I wanna start, you've had really a, an extraordinary career, uh, in health and public health. You started out as an emergency room physician, then you became a, a local public health leader in Texas, uh, in a couple places. Then you became a secretary of health in Washington State, and now you're working for Phamily and sort of the health system more generally.

I, I'd love to hear a little about your path, you know, how you sort of moved from one of those kinds of positions to another, and what drew you to public health from the ER world?

Umair: Yeah, that's a, that's a great question. It's, uh, um, I won't go into all the details. There is a lot, a lot, as you know, in all these career paths, there are always twists and turns and ways that you actually go.

But, um, let me even go a little bit further back before I even got into my training. When I was in, uh, medical school, I was reading something that wasn’t gonna be on any of the tests, which by and large meant that a lot of my fellow medical students didn’t read it. Uh, and it was the eradication of smallpox.

And that was, you know, as you know, in the 50s and 60s, eradication of smallpox by WHO was their main goal. And in 1977, you had the last case of smallpox. '78, it was, it was deemed, uh, the world was free of, of, uh, wild smallpox. And here I was, uh, a medical student reading this, and I said, you know what? Wow, I wanna go and see what public health and global health and population health and, and WHO, what this is all about.

Um, so fast-forward, when I, um, came out of my training, I was initially a primary care doctor. Uh, I was, um, overseeing two federally qualified health centers in southeast Texas. Then became, as you said, an emergency care physician, uh, at Texas Medical Center.

What I realized was that we spend so much time taking care of people in the clinical setting. But at the end of the day, what really impacts their health is what happens in the non-clinical setting. It's where they live, it's where they shop, it's when they travel, it's what's happening in their home or their schools or their, or their work environment. It's, it's in the community.

And so that love of public health from what I had learned from way back in training and WHO and, you know, global, as well as really picking up that as I was seeing my patients, I felt powerless or less po- empowered to be able to really help their lives when a lot of those impacts were what happened in the social realm of things.

And so I set on this journey, and that's where I went to, uh, from a smaller health department in Texas to then, uh, you know, health department that was the third lar- for the third largest county in the US, right? Five million people. And it wasn't just that it was five million people. It was a, it was a county and a community that constantly was under duress.

We had, um, emergencies from, from hurricanes to tropical storms. We were responding to what was happening in Dallas with Ebola. We had Zika, we had H1N1. And so we were constantly under emergency. And guess what? COVID-19 hit. And I spent that first year with my team, doing everything we could to share what we thought was going to really help people be safe and protected.

And then, um, the governor for the state of Washington, his team saw me, uh, doing some of these media things across the country and asked me to join to be his, uh, cabinet secretary. And I actually arrived the week that COVID vaccines were coming out.

Michael: Really? I didn't realize.

Umair: So here as a ER doc who, you know, is now a public health practitioner for many, many years through all these emergencies. So I saw clinical care in the emergency environment. I also saw it in this, you know, big zoomed up community emergency environment in disasters. And now all of a sudden, I was given the biggest, um, challenge, which was: How do you vaccinate eight million people across the state of Washington? And, uh, we did it.

And then fast-forward from that is, um, uh, last year I made the decision to step down, um, as the secretary of health. And then, um, just a few months ago, I started as the chief medical officer, uh, for Jaan Health, which, uh, we'll talk about, but family with a PH. Uh, family, uh, meaning sort of providers, patients, as well as the H for health. Um, and how do you bring that all together for proactive care management?

That actually ultimately has been my journey and it's been interesting because the journey has been about government and public service, which has been so critical after twenty, twenty-five years of service. What I, what I found very lately was that I felt government had gotten stuck. That we, we can't seem to find common ground, right? The trust in government, trust in institutions, trust in science, trust in things that we over time have valued, has really diminished. And so I felt like I could make a difference being outside of that system to be able to help, really, people ultimately in communities across our country.

Michael: Wow. It's quite a story, quite a career so far, although with a lot left to go and–

Umair: I hope so!

Michael: ...and a lot for us to talk about. I mean, you've sort of set the stage for, for, multiple conversations here, uh, this, this morning. Um, I actually wanna take you in a sense from that student in med school reading about smallpox to today, uh, and some of the work you're doing in Phamily, and really talk a little bit about the interest you have and the work you're doing both in new technologies and in AI.

You know, there's a lot of discussion of AI everywhere and how is it gonna play out, how is it gonna impact the economy, how is it gonna impact healthcare. I'm particularly interested now in how you think AI and artificial intelligence more generally is gonna impact our public health sector, our public health system more generally. Where does AI fit, uh, in the public health agenda from your perspective?

Umair: Well, I think the first thing, Michael, is that it's here to stay. It is not going away. So we cannot put our head in the sand and say, "I'm not gonna deal with AI. I'm not going to see how this can make my life more effective or more efficient." But I think when you hone in on your question about how does AI work with health, I think that's a really interesting place. Um, we know the vast majority of impacts that are on people's health happens in the community.

Michael: Right.

Umair: If we were to design a healthcare system, we wouldn't design it the way we would, right? Our current system is really designed for episodic care. It's, uh, care when somebody, uh, gets sick, somebody gets injured. It's really about those acute insults on people's lives.

But we also recognize that the vast majority of cost in this country is on chronic care. It's on the diabetes or the high blood pressure or the heart disease or a mental health condition or somebody who's gone in, uh, on dialysis. These are unfortunately some vastly important but incredibly key areas of cost in our country.

So if we were to redesign a system, we would want better understanding of what's happening in the community when we're designing what's happening within our system. And healthcare delivery is not separate from what's happening in public health or population health. Public health, population health – and I'm using those interchangeably knowing that there is a difference – is ultimately about how do we build communities that are stronger, that are healthier. And you can't do that if you don't take advantage of what the resources and tools that are there.

So here's the challenge. We've got AI and tools that are out there, and I would say that there's a real issue in public health and, and, even healthcare delivery where we just don't have enough people. And we don't have enough of the people with the tools to be able to advance the work that they need to do, and we're overwhelmed with data and information that's just not useful because it's too much noise.

What AI does is it allows us to empower the people with the tools to really take care of this overwhelming data and information overload structure and makes it more effective, more efficient, while we're also streamlining the costs of what's happening in the labor side and also helping our patients. All that together is what's exciting about

Michael: Right. Let me switch gears a little bit and talk about sort of this complicated time that state and local officials around the country are having right now in this very decentralized, fragmented public health system we have with over three thousand state and local health departments, various federal agencies, uh, and so forth.

Um, we're seeing a situation in which federal officials, uh, whether it's around vaccines or certain other topics, are actually proposing policies that for many in the public health community, particularly many at the state and local level, are at odds with the scientific training and knowledge that they have. Uh, and so they're caught in this, this difficult situation. You travel the country a lot, you speak to colleagues a lot. What does it look like from a state and local perspective? Uh, what are you hearing?

Umair: Yeah. I mean, you know, there are concerns. I mean, there, uh, it's not limited to the geopolitical context of red-blue. I think it's really about programs that state and local health agencies have been relying on for many, many years, on a quick dime have all of a sudden stopped. They've, you know, ceased funding. Um, they've had to pivot for other means, uh, to serve communities. And this is the real challenge.

So what I'm hearing from people, whether they're in, um, more conservative contexts or more, um, liberal contexts, red, blue, purple, what I'm hearing is this concern that it's happened really quickly. But what I've also heard is that because of that, the next thing they say is, "And so then we partnered with somebody," or, "We did this," or, "We found some other way around it." And so what I've really been impressed by is the ability for, for public health leaders to be nimble and have been really savvy about how do they, again, find ways to – do you remember that show MacGyver?

Michael: Yeah, of course. Yeah, I do.

Umair: Yeah. You have gum and you have a paperclip and a matchbox, and the next thing you build a, you know, a house. Right. And you're like, "Okay, we-"

Michael: We did it!

Umair: That’s – there's concern 'cause it's happened fast, but it's also pushed many to then be able to find these incredibly different opportunities to be able to do the work. But the reality is that we are caught in a very difficult time right now, Michael, and as you know, I'm, I'm, you know, teaching at, at Columbia, and the, the title of my course is Navigating Health in a Divided Nation.

And what we've been really talking about is like, what are the skills do we, that we need in order to navigate health? And where I'm going with this, Michael, is just a very simple concept that there are certain things in public health that we feel very strongly about, and we should. Those values should be there. So what are those lines in the sand? Maybe for, for, for most, it's vaccines. Vaccines save lives. We wanna make sure you do not pull back on vaccine policy.

But there are other aspects of health that have gotten into the tent of public health that are really eh. Data are kind of iffy or it's on the periphery and, and yet we still clench on as if it's just as important as the core work of public health. And what I would argue is that when we do that, we dilute our message, and that's been one challenge. And the second challenge is: how do we then talk and frame and communicate health to those who aren't as familiar with public health?

Michael: Yeah. And, you know, there are aspects, and I assume you would agree with this, of sort of the Make American Healthy Again agenda around pesticides, around healthy living, et cetera, where there, there are areas for, for collaboration and growth and public health messaging that, that sort of goes, that blurs those

Umair: This is controversial, but I will say that, um, I, in the class, uh, showed two examples side by side. One was Make America Healthy Again and I also showed the example Be Well Washington, Be Well Wa, which was our program that we had put together before I left that was really also very similarly about health.

Michael: Health, yeah.

Umair: And what I found fascinating is that when you take the, the core elements of both of them, they actually match up.

Michael: Yeah.

Umair: But these are from two geopolitically, on the spectrum of red-blue, you could not be any more diametrically oppositional than this. Yet we come together. And what, what, I think this reminds me is that health is still a unifier in our country. It can divide us, absolutely. Health is – public health especially has become inherently political, but it doesn't have to be partisan.

Michael: So let me ask a different kind of question. One of the ways that public health used to provide services to a much greater extent than it does now was through some direct clinical care services. And people feel that they get value when they actually, you know, get an immunization or have an adult well care visit, et cetera. And I know there are counties around the country, and Harris County is one of them, that still provide clinical care services.

There then was a moment where the public health community said, "No, we're under-resourced, we're undervalued. We're gonna shift away from providing clinical care, uh, and focus much more on sort of the population. We're gonna leave it to the community health centers and the outpatient clinics, et cetera, et cetera." And I understand that argument.

What's your thought on the role a local health department should play, whether it's a safety net provider or some sort of provider, in actually providing direct care services to, to community members?

Umair: I think, I think we need to do that work if no one else is doing it. The safety net is the key words there, uh, are the key words there, because when, when, um, no one else is gonna do that work, then public health agencies, as they have done for decades, will step up and should step up. But we should also be smart about it.

If we don't do something well, and we saw, we did this in, in Harris County, where there were some services, direct clinical services, that we just didn't do so well. And guess what? We moved them over to another agency, and they did it better. And then we were able to focus on other things. And I think that value proposition is very hard. Um, and so I, I think it's, it's really about ultimately knowing what we want to accomplish and then accomplishing that in a way that allows us to be successful.

Michael: Yeah. It's knowing what your particular health department's niche is, what you can do directly yourself, what you connect with others to do, and how you bring others together. I mean, it's sort of how you figure out that, that circle.

Umair: And these are, these are times – and again, this is where turbulence comes in – when, when, you have such a, a, a transformation of the system, when there's such a shock to the system, Michael, what it does is it forces you to really ask those questions. Whereas in a blue sky day, you don't have to ask it.

Michael: Yeah. The world is our oyster.

Umair: Not that public health has ton of resources, but, but at least public health is able to say, "We have, we have what we need." And so now it's that you don't have what you need, and so we have to really think about what is the core programming that we need to deliver, and I think that's a key part of it.

Michael: I have to ask you, one of the experiences that you've had that's really interesting is that you were the leader of a couple of local health departments in Texas, which is a very decentralized state where the locals have a lot of authority. And you also were the leader of a state, uh, secretary of health, health secretary, um, also in a decentralized state where locals believe in home rule to a large extent.

W hat did you learn about leading at these different levels of our fragmented system? I mean, when you arrived, I think it was December of '20 or whatever in, in, in Washington State in Olympia, and now you were wearing the state hat as opposed to the local hat. How different did that feel? How did that experience as a local leader help you? How did that play out?

Umair: Yeah, you know, it's interesting you bring that up, and, uh, I, I would say that ultimately it's about, people and relationships. Um, what I, what I found was that people didn't see me in the same way, right? So I used to be their colleague.

Michael: Yeah.

Umair: and now all of a sudden, I was a state health secretary, and I became, you know–

Michael: That person.

Umair: That person over there that was, you know, doing bad things. And, um, what I realized is that in time, we all have to play our roles. And I'm hopeful that the role that I played was to, at a very difficult time in the state of Washington and in our country, was to help transform, uh, what we needed to do.

So I would say, uh, it was awkward, it was difficult, but it was necessary because we were in the middle of an emergency. And now we're at a place where the next, uh, whether health secretary in Washington or the next commissioner in Harris County or, you know, go down the list of people, uh, who I've, I've either impacted or who came after me, I'm hopeful that what I left is gonna allow them to build better.

Michael: Well, your tenure as Secretary of Health in Washington State was quite a successful one, uh, from my perspective. Washington has long been a leader, um, and continues to be a leader. But I think the work you did around equity, the work you did around trying to reduce disparities, the work you did around trying to navigate through COVID during that era was really remarkable. And I wanna thank you for, for being with me this afternoon, and, uh, look forward to continuing our conversation over time.

Umair: I love it. I wish, uh, your, your, uh, listeners could, could see this, but I have, uh, a, a little bag that I'm gonna be giving the students. And it's interesting because it's got, uh, two, uh, football players in it.

Michael: Tell me about it. Yeah.

Umair: They're, uh, one's, uh, dressed in red and one's dressed in blue, and there's a little chocolate that's also in red and blue. And, uh, the message is that I see public health as being the offensive line of a football team, and everybody focuses on the quarterback, the healthcare system, uh, that gets all the notoriety. And so what I'm telling them is, thank you for being the offensive line of that football team, because they're the ones that are the future of our country and they're gonna certainly help us bring, um, that, that connection back.

Michael: What a, what a nice message both for your students, but also for our listeners and, and for all of us. And, and what a perfect way to end this conversation, uh, at least for now. Thank you so much, Dr. Umair Shah.

Umair: Thank you, Michael. Thank you so much for having me.

That was Umair Shah, Chief Medical Officer of Phamily Health, and former Health Commissioner of both Washington state and Harris County, Texas. What an interesting and thoughtful discussion of key topics on the public health agenda, ranging from how AI could help local health departments to the role local public health agencies might play in providing clinical care.

As I reflect on our conversation, a few items stand out.

First, while there is much uncertainty about how AI will influence public health going forward, Umair highlighted one important path that we should emphasize right now. Put simply, we live in an era in which the PH WF needs to better understand the social and medical needs of their community. At the same time, the public health leaders lack the workforce to capture and refine the needed data to achieve that task. But AI can provide these under-resourced public health workers with the ability to more effectively and efficiently use data to improve community health.

Point two, in our fragmented public health systems, there inevitably are turf battles between leaders at different levels of government. Umair lived this balancing act when he transitioned from a county health commissioner in Texas to a state Health Secretary in Washington state. The lesson, navigating inter-governmental politics is a key feature of effective public health leadership.

Point three, there are widely divergent views on the role local public health agencies should play in providing clinical care to local community members. Umair’s view is that public health needs to play a safety-net care role when nobody else is providing needed services. But he adds that there are risks in doing so, both because local agencies might not be effective in providing such services, and even if they are, the resources needed could divert from other key public health priorities.

Point four, while there are many points of conflict between the RFK Jr. MAHA agenda and the longstanding goals of state and local public health officials, there also are areas of overlap and potential collaboration. Umair illustrated this point nicely when he told us how closely the BeWell Washington agenda he led as the Health Secretary in that state overlapped with many elements of the core MAHA agenda. Trying to build off those areas of overlap is a key priority going forward.

Finally, as a fan of both organized sports and of public health, I loved Umair’s metaphor in which he compared public health workers to the offensive line in football, whose job it is to protect the team’s quarterback. In my view, the quarterback here is the health of the community, and the public health worker is behind the scenes protecting and promoting that effort. What a unique, and inspirational way of thinking about our public health workforce.

And on that note, we come to the end of this episode of Who the Health Cares.

Join us again in two weeks for our final episode of the season! And this time, I’ll be in the guest chair to discuss my research on Indiana and Kentucky.

Till then, this is Michael Sparer, signing off from the Center for Public Health Systems, at

Columbia University.

This episode was produced by Grace Rubin.

Our sound engineer is Zoe Denckla.

Alex Weaver is our social producer.

Fact-checking by Monica Stanovic.

Rachel Ferat is the Program Manager for the Center for Public Health Systems

And Rebecca Sale is the Head of Strategy and Partnerships for the Center for Public Health Systems.

Thanks to all of you!

Resources:

Umair A. Shah MD MPH - Phamily

Social Determinants of Health - Healthy People 2030 | odphp.health.gov